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Documentation for Documentation's Sake

Walker, Graham MD

doi: 10.1097/01.EEM.0000476274.94731.a6

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT (, a number-needed-to-treat tool to communicate benefit and harm. Follow him @grahamwalker, and read his past columns at





Merriam-Webster, if you need a definition of farce, I think I've found one.

A friend in Denver was recently told that his hospital was going to focus on hand hygiene, and that “secret shoppers” would be watching and documenting whether everyone “gelled in and gelled out.”

The catch? It doesn't count if you wash your hands inside the room as you're leaving because the secret shoppers can't see you washing your hands. So the ED staff was asked to clean their hands only outside of the room so the hospital could show 100 percent compliance.

Ladies and gentlemen, we've swung so far from focusing on patient care to focusing on ridiculous, silly, surrogate outcomes and documentation that sometimes I wonder who is captain of the health care ship: a care provider or a bureaucrat?

We've all heard the adage, “If you didn't document it, it didn't happen.” The phrase has always felt unfair to me, as if you're guilty of being a bad physician unless you've documented your innocence. To be completely honest, the fact that the medical record became a legal document has created a huge number of problems for our health care system, causing note bloat, copy-and-paste medicine, less time for patients — and less attention to them. Electronic medical records have only accelerated this problem. Author and TED lecturer Abraham Verghese, MD, talks about treating the “virtual patient” instead of the actual human in front of you, and I don't disagree at all.

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Big Data

But now that we practice “population medicine” with “Big Data,” (which all started with “quality metrics” and the “outcomes” movement), the medical record is now being used for auditing and regulation, and has strayed even further from the entire point of a medical record. (Hint: It was not developed to tell Medicare that cultures were drawn before antibiotics were given.)

And this is not even the main bee in my bonnet this month. It's a step even further away from actually helping a patient. It's the concept of “documenting in the right place.” Instead of “if you didn't document it, it didn't happen,” this is “Even if you documented this properly in your note or on this one screen, if you didn't document it in this other place, it didn't happen or it doesn't count.”

Let's be very, very clear about this: Documenting provides absolutely not one iota of “quality” to the patient (reminder: why we are in health care to begin with?), yet it seems to be more important than patient care or communication skills if you believe your administrator.

I attended the Essentials of Emergency Medicine conference this year, and colleagues from across the country reported the same experience. If you documented vital signs in your physician note prior to discharge but they didn't also get documented in the Holy Vitals Flowsheet, then apparently no vitals were ever done prior to discharge. Medicine is quickly moving toward a “getting dinged via database” system, where something did not happen if an EMR analyst can't find a piece of data in his database query. (And the bean counters are too busy to actually investigate; it's much easier just to assume the medical staff didn't do it and provide punitive feedback.)

Other physicians told me that when they documented their procedural sedation in the “wrong spot,” they got a nasty-gram from an administrator that they gave propofol without proper physician documentation, which of course then generated the typical exchange:

“Seriously? I could have sworn I documented that. I always do.”

Open patient's medical record, and find it documented correctly.

Email administrator, “Not sure what you mean. It's all there. Are you sure you're looking at the right patient?”

Administrator replies, “Oh, I see now. You didn't document it in the procedural sedation tab, so it came up as undocumented.”

Grumble, eye roll, sigh.

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Onus on Physicians

This issue is coming to a head in medicine, and it feels like it's a binary option: administrators vs. physicians. Quality metrics, outcomes, and population medicine vs. the individual patient. Checkboxes for the entire medical record vs. prose. Assumption of guilt vs. assumption of innocence. People talk about this all the time: the loss of the heart and soul of medicine. Template and factory medicine, algorithms vs. care customized to a particular patient.

We're now at a point where even if you made a great save or a miracle diagnosis that only Dr. House could achieve, you may be viewed by your friendly local administrator as a liability because you “didn't do it right” if you didn't add it to the problem list and click the box for “primary diagnosis.” (Regardless of the fact that the medical care you provide keeps the hospital running and pays the administrator's salary.)

Let's be very clear: I'm not against population medicine or Big Data or outcomes analysis. (Actually, I've personally seen multiple sides of this: I've done research reviewing 400+ records as part of a chart review study we published and mined administrative data for other studies that I've published.)

These macro-data analyses are all potentially revolutionary and a natural step in an evolving medical care system. But putting the onus on the medical staff to “document to make it easy on auditing” is absurd. Our IT departments should build systems to analyze the necessary data and abstract it if it needs collecting, but keep those of us trying to provide care out of it.

The medical record cannot and should not be the only way to evaluate anything and everything in the health care system, and with every additional “template bureaucratic phrase that fulfills subsection 2C-423.51 requirements” that we add to it, the less useful it becomes to the actual people who use it on a daily basis: the physicians seeing the patients.

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